Basic Information
| Provider Information | |||||||||
| NPI: | 1790083822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PREMARAJ | ||||||||
| FirstName: | THYAGASEELY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | B.D.S, PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 290370 | ||||||||
| Address2: | |||||||||
| City: | FT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333290370 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542624346 | ||||||||
| FaxNumber: | 9542622269 | ||||||||
| Practice Location | |||||||||
| Address1: | 3200 S UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333282018 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9542627213 | ||||||||
| FaxNumber: | 9542627355 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2011 | ||||||||
| LastUpdateDate: | 09/23/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 09/22/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223X0400X | 118 | NE | N | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics | 1223X0400X | DTP716 | FL | Y | Dental Providers | Dentist | Orthodontics and Dentofacial Orthopedics |
No ID Information.